Provider Demographics
NPI:1811093719
Name:BROUDER, DIANE ELAINE (LMFT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ELAINE
Last Name:BROUDER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:ELAINE
Other - Last Name:BROUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:3 WILDWOOD MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1155
Mailing Address - Country:US
Mailing Address - Phone:860-303-4108
Mailing Address - Fax:860-400-3043
Practice Address - Street 1:3 WILDWOOD MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1155
Practice Address - Country:US
Practice Address - Phone:860-303-4108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2021-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000597CT106H00000X
CT000597106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004212635Medicaid
CT000597OtherCT STATE LICENSE FOR MARRIAGE AND FAMILY THERAPY